Medicare Part B payment allowance limits for drugs not otherwise classified - Effective Jul 1, 2022 through Sep 30, 2022
Drug name | Dosage | Payment limit | Notes |
---|---|---|---|
Alfentanil Hcl | 500 MCG | 0.851 | |
Allopurinol Sodium | 500 MG | 2741.738 | |
Aminocaproic acid | 250 MG | 0.314 | |
Aztreonam | 500 MG | 13.988 | |
Bortezomib (Dr. Reddy's) | 0.1 MG | 23.125 | Added July 2022 |
Bumetanide | 0.25 MG | 0.307 | |
Bupivacaine | 1 ML | 0.113 | |
Clindamycin Phosphate | 150 MG | 0.954 | |
Coagulation Factor IX, Recombinant (Ixinity) | 1 IU | 1.746 | includes clotting factor furnishing fee |
Diltiazem Hydrochloride | 5 MG | 0.295 | |
Doxycycline Hyclate | 100 MG | 16.117 | |
Esmolol Hydrochloride | 10 MG | 0.297 | |
Famotidine | 10 MG | 0.329 | |
Flumazenil | 0.1 MG | 0.885 | |
Folic Acid | 5 MG | 3.029 | |
Glucarpidase | 10 UNITS | 362.572 | |
Glycopyrrolate injection | 0.2 MG | 1.585 | |
Immune Globulin (Panzyga) | 500 MG | 69.35 | |
Labetalol Hcl | 5 MG | 0.13 | |
Metoprolol Tartrate | 1 MG | 0.146 | |
Metronidazole inj | 500 MG | 1.425 | |
Nitroglycerin | 5 MG | 1.29 | |
Olanzapine short acting intramuscular injection | 0.5 MG | 1.098 | |
Paliperidone Palmitate (Invega Trinza) | 1 MG | 11.181 | |
Rifampin | 600 MG | 68.27 | |
Sodium Chloride, Hypertonic (3% - 5% infusion) | 250 CC | 1.36 | |
Sulfamethoxazole-Trimethoprim | 400-80 MG | 0.677 | |
Vasopressin | 20 UNITS | 189.538 |
microCurie 100% AWP = $176.640; microCurie 100% WAC = $147.200
"lesser of" methodology applied
Added July 2022